The Challenges Lived and

The Lessons Learned

Teaching Nursing in

Cambodia

Dr. Karen Reed, RN

Clinical Assistant Professor

University of Florida

College of Nursing

Once upon a dare……

Cambodia is a poor

country in Southeast

Asia with 80% of 14.4

million people

surviving as

sustenance farmers. (Cambodian Ministry of Health

[MoH], 2011)

Cambodian health

remains the lowest in the

Western Pacific Region

and ranks 174th out of

190 countries. (World Health Organization [WHO], 2010).

Only 12% of

Cambodian

homes have

electricity. (US Ambassador Todd,

Interview, 2012)

Population: 14.9 million

Average Age: 23.3 years

Infant Mortality:

55 deaths/ 1,000 births

Maternal Mortality:

250/ 100,000

Life Expectancy: 62 years (Central Intelligence Agency [CIA], 2012)

Countries in

SE Asia

Number

Physicians

Number

Nurses

Cambodia .16/ 1,000 .61/ 1,000

Vietnam 1.22/1,000 1.01/ 1,000

Laos .27/1,000 .97/1,000

Source: World Bank, 2010

Killing Cave used by Khmer Rouge, Kampot

Non-communicable Disease Burden:

Urban Areas:

10% of adults have

diabetes

25% high blood

pressure

Rural Areas:

5% of adults have

diabetes

12% hypertension

Cigarette Use:

48% of men

3.6% of women

Chewed Tobacco Use:

17% of women

1% of men

Land mines and road accidents are the most significant causes of traumatic injury and death in peacetime Cambodia.

Land mines are particularly serious for children and youth who attempt to salvage unexploded ordinance to sell it as scrap metal (UNICEF, 2009).

Traffic Fatalities

Second Leading Cause of Death

1979:

20 physicians (45)

26 pharmacists

28 dentists

728 medical

students

20 nurses

The Health System:

Starting Over

Level 1: Operational Districts Serving

100,000 - 200,000 pop

Referral Hospital & Network of Health Centers

Level 2: Provincial Hospital & Provincial Health

Department

Level 3: Ministry of Health, National Institutes,

National Hospitals, National Programs, & Training

Institutions

8 National Hospitals

73 Operational Districts

67 Referral Hospitals

823 Health Centers

The Health System: 1995- Present

There are 5 public nursing

programs in Cambodia:

•Technical School for

Medical Care

•Kampot RTC

•Stung Treng RTC

•Battambang RTC

•Kampong Cham RTC

RTC= Regional Training Center

Dormitory in Kampot

TSMC, Phnom Penh

Kampot RTC

Cambodian Nursing Education System

Bachelor’s Degree – 4 years

(only TSMC)

Secondary Nurse- 3 years

Primary Nurse- 1 year

Secondary Nurse Midwife- 3 years

Primary Midwife- 1 year

Secondary Nurse/ Midwife- 3 + 1 (not

Stung Treng RTC)

Secondary Nurse/Dental Nurse- 3 years

(only Kampong Cham RTC)

Cambodian

Nursing Classroom Resources (Sources: Direct Observation, Cambodian Interviews, & JICA)

Out- dated libraries in 4 of 5 nursing

programs. Stung Treng has no library.

3 of 5 programs have equipment in

poor condition. TSMC and Kampot

RTC have best maintained equipment.

Faculty are not permitted to use

equipment in some programs and/ or

faculty lack knowledge of use.

Cambodian

Nursing Classroom Resources (Sources: Direct Observation, Cambodian Interviews, & JICA)

Nursing lab (demonstration room) in 4 of 5 nursing programs; however, Battambang RTC has their nursing lab on the roof. Stung Treng has no nursing lab.

Typical classroom size: 90-122 students in room

Typical classroom: long and narrow; overcrowded

Challenges:

The Ministry of Health oversees the funding, staffing, and content of the five regional training centers that provide a

three year nursing program.

No nationally specified terminal program outcomes.

There is program inconsistency on the subject matter taught.

Faculty lack baccalaureate or advanced nursing degrees and academic preparation in education principles associated with course construction, teaching methodologies, and evaluation.

Cultural Considerations

"Culturally congruent" education is

education that is "provided in a manner

that is meaningful and useful“. (Cr ane, 2006).

Nursing education must be presented

with the local cultural, religious,

economic, social environmental and

political influences in mind (Mur r ay, 2005).

Challenge:

Rules of Propriety and Attitudes

About Time

Do I move my hands,

arms, body location?

Use of touch?

Meeting/ Greeting

Gaining Attention

Giving Praise

Emphasizing

Giving Correction

Challenge:

Adapting Our Teaching Techniques

Abroad Which Work Well in the US

Teaching Methods

Work sheets and color pencils

Teams were used to develop nursing care plans/answer case study questions

Games, such as Jeopardy, to encourage learning and promote active interaction.

Donors provided pen lights, ink pens, clips, tote bags and candy for prizes and gifts.

Same- Same,

but Different!

Use of Stories

Preparing Outlines

Be Clear and Culturally Alert

Make Lecture Information Personal

Invite Listener Questions

Use Illustrative Examples

Simplify the Vocabulary

Repeat & Summarize Carefully

Repeat and Repeat Again

Break up Lecture w/ Demonstrations & Breaks

Challenges for Cambodian

Nursing Education

Lecture plans are not based on evidence, are not scientific, and are poor in quality.

Faculty lack appropriate teaching knowledge and skills.

Faculty do not supervise students in clinical setting

No mentoring of nurses in provincial hospitals on how to supervise nursing students

Nurse: Student Ratio in clinicals 1:20-35

No incentive for nurses to supervise nursing students.

English Language &

Cambodian Nursing Faculty (Sources: Cambodian Interviews- 2012 & Japan International Cooperative Agency- 2011)

Nursing Programs were asked to

self-report English speaking skills of

faculty to JICA.

3.4% Very Good (N=3)

89.7% Good (N=78)

Direct experiences at all 5 nursing

programs found a very different

situation. (11/1/6)

Challenges for Cambodian

Nursing Education (Sources: Direct Observation, Cambodian Interviews, & JICA)

No textbooks in Khmer (major language) Textbooks are not available to students English language lessons are not

available to students in 4 of the 5 nursing programs.

Nursing programs are not internationally recognized due to limited quality and content.

WHO has a collaborative program with the University of the Philippines to create a “bridge program”. Piloted in TSMC.

Challenge:

Cultural Hurdles

Political Hurdles

Structural Hurdles

Child Trafficking

Lack of Resources -

Environment

Lack of Clean Water

Lack of Safe Food

Environmental Concerns Beyond Capacity

(arsenic in ground water)

Future Directions

There is a need for Cambodian nurses to

learn the leadership skills necessary to

foster the role of professional nursing in

Cambodia’s

health care

system.

Future Directions There is a need to expand the current

nursing education options to include

BSN and graduate programs, with

access to such programs either in- country

or via distance programs.

Future Directions There is a tremendous need for masters

prepared nurses to assist Cambodian

nursing faculty in developing their

educational delivery skill set and knowledge

base.

Future Directions

There is an opportunity for nursing programs

in developing nations to work together to foster

nursing education/ health care in Cambodia.

Questions?